Low major bleeding, pump thrombosis and death rates in continuous flow left ventricular assist devices patients with good anticoagulation control

Background

Continuous-flow left ventricular assist device (CF-LVAD) patients require anticoagulation with vitamin K antagonists (VKAs). Good versus suboptimal anticoagulation control expressed as high versus low time in target range (TTR) of international normalized ratio results in less clinical events in atrial fibrillation patients. However, data in CF-LVAD patients are lacking.

Purpose

To study the association between TTR and clinical events in patients with CF-LVAD as destination therapy.

Methods

Single-centre cohort study in patients receiving CF-LVAD between 2010–2021. Patients were followed from start of VKAs until outcome or end of follow-up. Outcomes were combined major adverse events, thromboembolisms, major bleedings, neurologic events and all-cause mortality. The TTR (low vs. high; <50% vs. >50%) was calculated during the overall study period and over 1-month periods by the Rosendaal-method. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by Cox regression with time-dependent covariables, adjusted for confounding.

Results

74 patients were included; median age 63 years [interquartile range 58–68], 77% males and 60%ischemic heart failure. During 191 years follow-up, 39 combined major adverse events, 14 thromboembolisms, 21 major bleeding, 22 neurologic events and 38 deaths occurred. For 1-month periods, high TTR was associated with less combined major adverse events (HR 0.3 95% CI 0.2–0.7), major bleeding (HR 0.4 95% CI 0.2–1.1), thromboembolism (HR 0.3 95% CI 0.1–1.3) and death (HR 0.2 95% CI 0.1–0.5) (Table 1). Results considering the overall study period were similar.

Conclusion

Good anticoagulation compared with suboptimal control during 1-month and the overall study period in CF-LVAD patients with destination therapy is associated with lower rates of combined major adverse events, major bleedings, pump thrombosis and death.

Funding Acknowledgement

Type of funding sources: None.

Antithrombotic therapy and bleeding complications in patients with atrial fibrillation and active cancer

Background

Little is known about the extent to which an active cancer diagnosis increases bleeding and thromboembolic risks in atrial fibrillation (AF) patients. Data on major bleeding rates per antithrombotic management strategy are lacking in AF patients with active cancer.

Purpose

To examine the incidence rates of major bleeding per antithrombotic treatment in AF patients with active cancer and to examine whether cancer type impacts major bleeding and thromboembolic risks.

Methods

We used Danish population-based health care databases to conduct this cohort study. We included all incident AF (including atrial flutter) patients aged ≥50 years between January 1st 1995 and December 31st 2016, out of whom we identified AF patients who subsequently developed cancer. We used International Classification of Diseases 10th Revision codes to identify data on cancer type and outcomes (i.e. major bleeding, arterial and venous thromboembolism). We used Anatomical Therapeutic Chemical codes to provide information on antithrombotic treatment (e.g. no anticoagulant treatment, platelet inhibitors, vitamin K antagonists, direct oral anticoagulants, or a combination of antithrombotic drugs) which was evaluated as a time-dependent variable. The follow-up started from the incident cancer diagnosis until the occurrence of an outcome, death or the end of the two year follow-up. Incidence rates per 100 patient-years and adjusted hazard ratios were computed.

Results

22,996 AF patients with a subsequent incident cancer diagnosis were included in the study. These patients had higher major bleeding and thromboembolic risk compared to those without cancer, with adjusted HRs of 2.11 (1.99–2.23) and 1.36 (1.27–1.44), respectively (Figure 1). Highest bleeding risk was observed for intracranial and respiratory cancer, while haematological and respiratory cancer were associated with highest thromboembolic risk. Bleeding risk increased with increasing number of antithrombotic drugs and was higher in AF patients with active cancer compared to those without, across all exposure categories (Figure 2).

Conclusions

Patients with AF and active cancer are at increased risk of major bleeding and thromboembolisms than those without cancer. Treatment with dual or triple antithrombotic therapy in AF patients with active cancer showed very high bleeding rates.

Funding Acknowledgement

Type of funding sources: None.

Atrial fibrillation in patients with a history of cancer and risk of bleeding complications associated with antithrombotic therapy

Background

Up to one in four patients with atrial fibrillation (AF) has a cancer diagnosis. It is largely unknown to which extent a prior cancer diagnosis affects major bleeding and thromboembolic risk in AF patients. Moreover, data on major bleeding rates per antithrombotic treatment type are lacking in these patients.

Purpose

To examine the incidence rates of major bleeding per antithrombotic treatment in AF patients with prior cancer and to examine whether cancer type and the time-interval between AF and cancer influence major bleeding and thromboembolic risks.

Methods

This nationwide population-based cohort study included incident Danish AF patients aged ≥50 years between 01–01–1995 and 31–12–2016. Data on prior cancer, major bleeding and thromboembolisms (i.e. arterial and venous) were obtained from Danish health registries via International Classification of Diseases 10th Revision codes. We stratified according to prior cancer and by time between the AF and cancer diagnosis (i.e. <1 year, 1–3 years, >3 years), and cancer type. Data on antithrombotic exposure (e.g. no anticoagulant treatment, platelet inhibitors, vitamin K antagonists, direct oral anticoagulants, or combination of antithrombotic drugs) were evaluated as a time-dependent variable. We computed incidence rates per 100 patient-years and adjusted hazard ratios in a Cox regression model.

Results

We identified 39,178 AF patients with a prior cancer diagnosis. Bleeding risk increased with increasing number of antithrombotic drugs and was higher in AF patients with a history of cancer compared to those without, across all exposure categories (Figure 1). The increased bleeding risk was similar across different time intervals between cancer and AF diagnosis. The increased thromboembolic risk steeply declined with increasing time intervals between AF and cancer diagnosis (Figure 2). Prior gastrointestinal, intracranial, haematological, respiratory and urogenital cancers were associated with an increased bleeding risk. The two latter cancer types were also associated with increased thromboembolic risks.

Conclusion

We showed that patients with atrial fibrillation and a prior history of cancer experience higher rates of bleeding than those without cancer. Both respiratory and urogenital cancers had the highest rates of bleeding and thromboembolisms.

Funding Acknowledgement

Type of funding sources: None.